- Email: [email protected]
Voice Symptoms, Perceived Voice Control, and Common Mental Disorders in Elementary School Teachers
ARTICLE IN PRESS
Voice Symptoms, Perceived Voice Control, and Common Mental Disorders in Elementary School Teachers *,†Iandra Kaline Barbosa, ‡Mara Behlau, §Maria Fabiana Lima-Silva, ║Larissa Nadjara Almeida, ║Hemmylly Farias, and §Anna Alice Almeida, *x║Jo~ao Pessoa, yNatal, and zS~ao Paulo, Brazil Summary: Introduction. Evaluating the relationship among teachers’ voice symptoms, perceived voice control, and common mental disorders (CMDs) might contribute to the understanding of the relationship between vocal wear and the teacher well-being. The understanding of this relationship may also help in taking more informed clinical decisions in voice rehabilitation when considering possible perceived voice control difficulties and the need to develop voice self-control strategies. Objective. The aim of this study was to determine the voice symptoms, perceived voice control, and CMDs in public elementary and secondary school teachers, and to analyze the relationships among these variables. Methods. The study included 85 public elementary and secondary school teachers of both genders. Four instruments were used to measure the variables: an identification and characterization questionnaire, the Voice Symptom Scale, the Present Perceived Control of Voice scale, and the Self-Reporting Questionnaire. Results. A significant correlation between voice symptoms and CMDs was found, along with correlations between the emotional domain of the Voice Symptom Scale and teachers’ ages and years of teaching. A negative correlation between CMDs and voice self-control was also observed. Conclusions. Teachers with voice symptoms had more CMD symptoms, and as the number of mental disorder symptoms increased, voice self-control decreased. Key Words: Behavior−Dysphonia−Teachers−Signs and symptoms−Mental disorders−Voice.
INTRODUCTION Among all the topics addressed in the research on teachers, the speech therapy has traditionally worried about voicerelated questions, due to the amount of departures from the learner activity related to voice problems, in addition to that the vocal problems can be considered as a work-related illness.1 Teachers among the professional classes are most affected by voice problems, with significant negative consequences, such as difficulties in teaching, communicating and social and emotional problems.2,3 Dysphonias are showed as vocal problems manifestations and could be from organic and/or behavioral origin.4,5 Teachers are often affected by vocal problems of behavioral origin, results from inadequate use of voice, although they may present any type of dysphonia.6,7 A feature of dysphonia is the presence of voice symptoms of an auditory or proprioceptive nature,8 including vocal fatigue, coughing, hoarseness, burning throat, voice failure, and shortness of breath when speaking.2 In voice professionals, such as teachers, voice patterns can play a greater or lesser role in the origin and maintenance of dysphonia; thus, vocal abuse or misuse Accepted for publication July 23, 2019. From the *Speech Therapy Graduate Program, Universidade Federal da Paraíba − UFPB, Jo~ ao Pessoa, Paraiba, Brazil; yUniversidade Federal do Rio Grande do Norte − UFRN, Natal, Rio Grande do Norte, Brazil; zHuman Communication Disorders Graduate Program, Universidade Federal de S~ao Paulo − UNIFESP, S~ao Paulo, S~ao Paulo, Brazil; xDepartment of Speech Pathology, UFPB, Jo~ao Pessoa, Paraiba, Brazil; and the ║Decision Models and Health Department, UFPB, Jo~ao Pessoa, Paraiba, Brazil. Address correspondence and reprint requests to Anna Alice Almeida, Departamento de Fonoaudiologia, Cidade Universitaria − Campus I, Centro de Ci^encias da Sa ude, Universidade Federal da Paraíba, Castelo Branco, CEP, Jo~ao Pessoa 58051-900, Paraiba, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 Published by Elsevier Inc. on behalf of The Voice Foundation. https://doi.org/10.1016/j.jvoice.2019.07.018
of the voice is directly related to the emergence of dysphonia, and this use could be related to the quantity and intensity of speech and lack of perceived control over one’s own vocal problem.9 The way in which the voice is used, whether in terms of the amount of speech or its vocal intensity, is a very individual characteristic and can be controlled through self-regulation. Self-regulation is a complex process in which the individual plays an active role in controlling oneself to achieve certain goals.10,11 Self-regulation is considered crucial to understanding behavior related to additive and abusive practices, such as smoking, drug use, alcohol, and obesity.12 This process can also be related to vocal behavior because voice use represents a social behavior and requires neuromuscular control, primarily developed for survival purposes.9 This fact has great importance to professional voice users. One study showed that people who have voice symptoms have lower self-regulation levels than those with no voice symptoms; in addition, as voice symptoms increase, there are decreases in impulse control and goal setting.9 Another study reported an experiment observing self-regulatory depletion related to vocal behavior and found that people who perform activities with a low demand for self-regulation can better control their vocal behavior. It is understandable that dysphonic individuals lose auditory motor control in noisy places, in addition to having difficulties with self-regulation, which together contribute to inadequate vocal behavior. Identifying the positive and negative elements of self-regulation in patients with voice disorders during assessments can be important in terms of treatment planning, goal setting, impulse control, practical measures in the patient’s daily life, and the generalization and maintenance of gains in vocal rehabilitation.16,17 In this regard,
ARTICLE IN PRESS 2 voice therapy requires the patient’s dedication and attention to practice new consciously learned behaviors; that is, the clinician must include the self-regulation process in voice therapy.16 Related but distinct from self-regulation is voice-related present perceived control, which is the extent to which the individual believes that he/she can currently control voicerelated events and symptoms, and how he/she reacts to these.13,14 It should be clarified that perceived control is not actual control but rather the assessment that the individual makes of his/her ability to regulate certain behaviors or emotional reactions. This control can be affected by the working conditions to which the teacher is subjected, such as long working days, excessive voice demands, large numbers of listeners, background noise, poor acoustics, distance between speakers, low humidity, dust and mold, stressful environments, and inadequate equipment.2 In addition to these issues, important new data have revealed a disturbing new element of teacher’s vocal health, which is the possibility of suffering from common mental disorders (CMDs). CMDs present as symptoms of anxiety, fatigue, insomnia, forgetfulness, irritability, difficulty concentrating, and somatic complaints.18,19 Patients with CMDs do not generally have a firm psychiatric diagnosis of an anxiety or mood disorder but rather present with symptoms inherent in these disorders. Stress resulting from inadequate working conditions can increase teachers’ voice symptoms and have negative effects on the quality of their performance.2,20,21 In this sense, in addition to voice symptoms being related to voice use, mental health issues may also be associated with voice use, rendering both the correct diagnosis and the treatment of teachers with voice problems difficult.22 High anxiety scores have been identified in teachers with greater numbers of voice symptoms.21 Another study confirmed that teachers with voice complaints have greater numbers of CMD symptoms, indicating the existence of emotional effects in the development and persistence of voice problems.2 Establishing the relationship between vocal symptoms, perceived vocal control, and CMDs in teachers would allow us to better understood vocal exhaustion and illness in this professional class. Furthermore, it is possible to make a more clinical decision based on vocal rehabilitation, considering the possible difficulties of vocal control perceived at the time of rehabilitation and the need to develop vocal self-control strategies. The aims of this study were therefore to measure voice symptoms, self-regulation, voice-related perceived control, and CMDs in public elementary and secondary school teachers, and to analyze the relationships of these variables with each other. It is believed that elementary school teachers present a high number of vocal symptoms, reduced perceived vocal control, and the presence of mental disorders symptoms. In addition, it is expected to find a relationship between these factors studied.
Journal of Voice, Vol. &&, No. &&, 2019
METHODS This study was approved by the Research Ethics Committee from Universidade Federal da Paraíba under protocol number 0824/2015. It was an observational cross-sectional field study, conducted with 85 public elementary and secondary (middle and high) school teachers working in Northeast Brazil. The eligibility criteria for participation in the study were as follows: being an active teacher; working in the Public Education Network; teaching in elementary and/or secondary schools; not having undergone previous voice therapy and/or not undergoing it at the time of the study; and participating in all stages of the study. It is important to know that the population of this study has a particularity related to their voice, besides not behaving like individuals who use the voice as instrument in their work. In this sense, teachers stand out from other individuals because of their vocal characteristics, high vocal demand and their perception of their voice often distorted. Table 1 reports the sample teachers’ work-related characteristics. The volunteer subjects were of both genders, mostly female (70.6%, n = 60). Most taught more than one subject (42.4%, n = 36), were elementary school teachers, that is, taught up to the fifth grade (41.2%, n = 35), and had two daily shifts (54.8%, n = 46). Eleven schools were randomly selected from a list of the public schools provided by the Department of Education of the participating municipality. Subsequently, a representative from each school was contacted to authorize the research at the institution. Then, all of the teachers at the authorized schools were invited to participate by the researcher during a visit. At this time, information about TABLE 1. Characterization of the Sample of Participating Teachers Variables Gender Female Male Subjects taught More than one Humanities Exact sciences Biology Physical education Languages Teaching level Elementary school Middle school High school Higher education More than one Workload One shift Two shifts Three shifts
N
%
60 25
70.6 29.4
36 16 13 8 7 5
42.4 18.8 15.3 9.4 8.2 5.9
35 14 17 1 18
41.2 16.5 20.0 1.2 21.2
31 46 7
36.9 54.8 8.3
ARTICLE IN PRESS Iandra Kaline Barbosa, et al
3
Voice Symptoms, Perceived Voice Control, and CMDs
the purpose of the study was given, and the teachers provided individual informed consent. Data collection included the Identification and Characterization Questionnaire; the Voice Symptom Scale (VoiSS),23 validated in Brazilian Portuguese24; the voice-related Present Perceived Control scale (PPC-V),14,25 culturally and linguistically adapted to Brazilian Portuguese; and the SelfReporting Questionnaire (SRQ-20),26 validated in Brazilian Portuguese.27 The Identification and Characterization Questionnaire is a standardized tool containing questions on personal data, general health, and specific features of the teacher’s profession. This included personal characteristics (such as age, gender, and region where they lived); occupation (education level, number of years teaching, teaching hours per week, and subject taught); and vocal characteristics and history (self-assessed voice quality, voice complaints, prior voice therapy for vocal disorders, absence from work in the previous year because of voice problems, and the need to change teaching style due to voice problems). The VoiSS, developed in England,23 is a self-assessment tool that determines the frequency of voice symptoms of an individual. In this study, the version of the VoiSS translated and validated for Brazilian Portuguese was used.24 The scale has 30 items assessing voice symptoms across three domains—impairment, emotional, and physical— with 10 items each, with answers scaled according to frequency of occurrence: 0 = never; 1 = rarely; 2 = sometimes; 3 = most of the time; and 4 = always. It thus has three partial scores and one total score, calculated simply as the sum of the partial scores. The total score ranges from 0 to 120, with higher values representing greater perception of symptoms and their consequences in daily life due to voice problems. It has a 16-point cutoff value and is considered a psychometrically robust classifier in terms of its diagnostic value for individuals with voice problems.28 The Perceived Control Scale − Stressful Events Scale was developed by Frazier et al25 and was adapted for the study of voice issues as the PPC-V scale.14 This protocol was adapted linguistically and culturally for Brazilian Portuguese before being administered to the teachers. The scale comprises eight questions, four positively phrased and four negatively phrased, which assess the individual’s perception of his/her current ability to control his/her vocal stressor or response to the vocal stressor. The answer scale ranges from 1 to 4, according to agreement with the following statements: 1 = totally disagree; 2 = somewhat disagree; 3 = somewhat agree; and 4 = strongly agree. Negatively formulated questions receive inverse scores. The mean value for a population of 820 respondents was 2.92 points.14 The SRQ-20, previously validated in Brazilian Portuguese,27 has 20 sentences for the assessment of physical and psychological symptoms, with dichotomous responses (yes or no) for aspects relating to somatization, depression, and anxiety. Results greater than 7/8 points for women and 6.5 points for men were used as cutoff points,29 indicating a positive SRQ score (possible presence of CMDs). In this study, a
cut-off value point resulting from a more recent analysis of this questionnaire was used. Descriptive statistical analysis was performed using Microsoft Excel 365 ProPlus to report the means, standard deviations, and frequencies of the analyzed variables, and inferential analysis was conducted based on Pearson’s correlation test. Devore’s30 proposed method was used to assess the strength of the correlations, indicating the degree of correlation according to Pearson’s coefficients, in which a correlation of 0.00−0.19 is regarded as very weak, from 0.20 to 0.39 as weak, from 0.40 to 0.69 as moderate, from 0.70 to 0.89 as strong, and from 0.90 to 1.00 as very strong. RESULTS The study included 85 public school teachers of both genders, with a mean age of 40.1 years old (§9.5). Table 2 presents the teachers’ work-related voice characteristics. Most of the teachers (50.6%; n = 40) assessed their current voice quality as good, had never had a medical consultation for a voice problem (61.2%; n = 52), and had never had a voice therapy session due to voice problems (57.3%, n = 64). Many teachers had missed work because of their voice (55.3%; n = 47), and the majority of teachers reported missing 1−3 days within the past year because of their voice (50.6%; n = 43), and reported that they had needed to change their teaching methods slightly because of their voice (41.2%, n = 35). TABLE 2. Characterization of the Voice Issues of Participating Teachers Variables Opinion about voice quality Excellent Very good Good Fair Poor Had a medical visit Yes No Had a voice therapy session Yes No Absence from work due to voice Yes No No. of days missed due to voice 0 days 1−3 days More than 3 days Changed teaching methods due to voice No A little Moderate A lot
N
%
4 8 43 27 3
4.7 9.4 50.6 31.8 3.5
33 52
38.8 61.2
20 64
23.5 75.3
47 38
55.3 44.7
38 43 4
44.7 50.6 4.7
28 35 17 7
32.9 41.2 17.6 8.2
ARTICLE IN PRESS 4
Journal of Voice, Vol. &&, No. &&, 2019
Table 3 shows the means and standard deviations of the vocal, behavioral, and work-related variables. The participating teachers reported having a mean of 28.3 (§6.53) students per class and 14 (§9.00) years of teaching experience. Regarding the total scores of the protocols used, there was a mean of 15.5 (§7.88) for the VoiSS impairment domain, 5.4 (§4.53) for the emotional domain, 9.1 (§4.91) for the physical domain, 30.2 (§14.55) points for the total score of the VoiSS, 4.3 (§4.25) points for the mean PPC-V, and 7.2 (§4.22) points for the SRQ-20. Table 4 shows a negative correlation between voicerelated perceived control and the presence of CMDs (P = 0.046) as well as positive correlations between CMDs and voice symptoms in the impairment (P = 0.002), emotional (P < 0.0001), physical (P < 0.0001), and total (P < 0.0001) domains. DISCUSSION Teachers constitute the category of voice professionals that has received the highest number of scientific studies in voice research.2,31 Since teachers experience intense voice demands, accumulation of activities, inadequate working environments, poor acoustics, lack of vocal training, and daily contact with elements harmful to the voice, they are more likely to develop dysphonia and to present with voice symptoms.2,19,21,24,32 If a teacher has a voice problem, it might mean that he/she must go on leave, thus harming his/her professional performance, compromising the longevity of his/her career, and generating frustration and feelings of worthlessness.21,32−35 In addition, in such conditions, the professional can require readaptation, which can result in personal, economic, and professional problems, as well as functional problems for the school.36 Most of the present study’s teachers considered their voice quality good, had never had medical visits or voice therapy sessions for voice problems, did not smoke, did not
TABLE 3. Means and Standard Deviations of Personal, Organizational, Vocal, and Behavioral Variables Variable
Mean
Standard Deviation
Age Mean number of students per class Years of teaching VoiSS impairment VoiSS emotional VoiSS physical VoiSS total PPC-V total SRQ-20 total
40.12 28.31 14.98 15.54 5.4 9.1 30.29 4.3 7.2
9.56 6.53 9.00 7.88 4.53 4.91 14.55 4.25 22.00
Abbreviations: VoiSS, Voice Symptom Scale; PPC-V, Present Perceived Control of Voice Scale; SRQ-20, Self-Reporting Questionnaire.
TABLE 4. Correlation Between Vocal and Behavioral Variables Variables VoiSS Impairment PPC-V − Total SRQ-20 − Total VoiSS Emotional PPC-V − Total SRQ-20 − Total VoiSS Physical PPC-V − Total SRQ-20 − Total VOISS − Total PPC-V − Total SRQ-20 − Total PPC-V − Total SQR-20 − Total
Test Statistic
P Value
0.009 0.337
0.936 0.002*
0.011 0.451
0.919 0.0001*
0.001 0.417
0.996 0.0001*
0.023 0.470
0.837 0.0001*
0.300
0.046*
* P < 0.05. Abbreviations: VoiSS, Voice Symptom Scale; PPC-V, Present Perceived Control of Voice Scale; SRQ-20, Self-Reporting Questionnaire. Test: Pearson’s correlation.
drink, did not have constant colds or other recurring issues, were physically active, reported hearing well, and had no family members with voice problems. Although teachers often consider their voice quality to be good, it does not indicate a lack of voice complaints or even of disorders. Often, these professionals tend to minimize voice disorder symptoms because they consider it simply to be an expected consequence of their teaching activity.37 Although the teachers perceived their voice quality to be good, many had to miss work due to voice problems and even change their methods of teaching. Research has shown that teachers with voice complaints mention experiencing more voice symptoms and self-assess their voice quality as worse than teachers without voice complaints,2 and teachers at vocal risk assess their voice quality as poor, whereas teachers without vocal risk self-assess positively, showing that the individual’s perception of his/her voice quality can be associated with the onset of voice symptoms.38 Most of the teachers in this study had high voice demands because they had to teach more than one subject, and they worked two daily shifts. Commonly, elementary school teachers (first to fifth grade) are responsible for teaching all subjects, which increases the voice demand and the need for vocal adaptations.39 Dysphonia in teachers can be due to associated external factors, such as high voice demand, large numbers of students in classes, inadequate working environments, large workloads, accumulation of activities, poor acoustics, and daily contact with work-related elements harmful to the voice.2,21,40 There is a prevalence of voice problems in teachers with workloads equal to or greater than 40 hours/week; that is, the higher that the workload is, the greater the use of the voice is, as well as the possibility of developing voice problems.41
ARTICLE IN PRESS Iandra Kaline Barbosa, et al
Voice Symptoms, Perceived Voice Control, and CMDs
A teacher’s high daily workload means that it is possible that working more than one shift will result in greater vocal demands and will consequently foster the emergence of voice symptoms.42 If a teacher develops dysphonia, it can lead to absence from work and can therefore be considered a work-related disease.1 This professional class routinely shows the need to take sick leave due to voice problems and even to leave their jobs permanently.43 Any change in these professionals’ voices can indicate the inability to perform their job duties and result in absenteeism, decreased productivity, and even the need to change professions.34 Many teachers report voice problems at some point in their lives, whether occasionally or frequently. The mean number of voice symptoms in the Brazilian population is 1.7, and in teachers, it is 3.5. Thus, at least one in every two teachers active have voice complaints and/or voice symptoms.35 The teachers participating in this study had a mean score that was higher than the VoiSS cutoff value, although the VoiSS cutoff was calculated for a general dysphonic population and not specifically for teachers. Considering that this value might be different for this professional category, the teachers in this sample showed similar characteristics to people with voice problems.24 The symptoms most commonly found in this professional category are hoarseness, vocal fatigue, a weak voice, voice failure, pain or discomfort when speaking, a dry throat, throat clearing, persistent coughing, and difficulty in projecting the voice. These symptoms could result from misuse or excessive use of the voice in poor working conditions that favor the emergence of occupational diseases.32 Another worrying aspect that affects teachers’ vocal health is the possibility that these individuals suffer from CMDs.21 In this study, the mean SRQ score was greater than the cutoff value, showing that the teachers in this study had a propensity toward CMDs, which involve symptoms of irritability, fatigue, insomnia, difficulty concentrating, forgetfulness, anxiety, and somatic complaints, often going undiagnosed and do not causing patients to seek medical care despite there being an apparent increase in these symptoms in several countries.18 Symptoms related to anxiety, stress, and depression can affect an individual’s voice characteristics and quality of life directly, especially in people who use their voices as a tool in their work, such as teachers.2,19,21,22 A strong, positive correlation was observed between voice symptoms and CMDs. The VoiSS scores in all domains were correlated positively with the total SRQ-20 score, indicating that the greater the number of voice symptoms is, the more frequent the presence of CMD symptoms. Individuals with voice problems commonly have a high prevalence of various types of distress symptoms, such as depression, anxiety, and/or somatic changes. This finding suggests the need for more studies on the relationship between these symptoms and voice problems.44 It has been shown that teachers with voice problems have higher incidences of depression and generalized anxiety disorder. In addition, there is a strong association between
5
behavioral dysphonia and psychosocial symptoms.45 Data such as these indicate the need for a greater focus by speech therapists on teachers’ voice disorders given the importance of the voice to their mental health since teachers who manifest voice complaints report more voice symptoms and have a higher prevalence of CMD symptoms.2 Another important finding in this study was the strong negative correlation between voice-related perceived control and SRQ-20 scores, suggesting that, the more psychosocial symptoms are related the lower the voice-related perceived control. This study design does not allow us to assess whether the psychosocial symptoms lead to decreased voice-related perceived control or vice versa. In the context of voice therapy, voice-related perceived control is the ability that the individual currently has to control his/her vocal symptoms, such as through behaviors or adaptations, and his/her perceptions of how the voice responds and adjusts to these episodes.14,42 The PPC-V was used to assess the voice-related perceived control of the teachers in this study. Although some research has found a strong relationship between voice symptoms (as measured by VHI-10) and voice-related perceived, no significant correlation between these two parameters was found in this study. In contrast, it was observed that this study’s teachers scored a mean of 4.3 points on the PPC-V, which was greater than the score found in the instrument’s validation study, which was 2.92 points.14 Self-regulation is the ability to voluntarily control one’s own thinking and behavior.16 It is a very complex phenomenon and involves many other aspects, such as activation, monitoring, inhibition, preservation, adaptation, and managing emotions and cognitive strategies to achieve the desired goals.9,13 The voice characteristics and working conditions of teachers, coupled with reduced voice-related perceived control and self-regulation, could lead to worsening the vocal condition and delay the search for treatment.43 Individuals with voice symptoms have shown lower levels of self-regulation than those without voice symptoms, and as the number of voice symptoms increases, impulse control and goal-setting scores decrease.9 Other studies have found that individuals with voice complaints and/or symptoms who are undergoing voice therapy are asked to make changes to their vocal behavior and must use selfregulation for this change to occur,15 either through goal setting or through impulse control. It is assumed that individuals with dysphonia have learned inappropriate vocal behaviors throughout their lives, so voice therapy demands attention and effort to change behavior not under conscious command.16 Although the relationship among anatomical, physiological, and psychological aspects has been much studied, the contribution of cognitive factors to the success or failure of this process has received little attention.16 The group studied is exclusive to teachers, therefore it is not possible to generalize the data, besides that the time of vocal symptom and the degree of vocal deviation are variables that could not be controlled in this research.
ARTICLE IN PRESS 6 Future studies will include comparison methods, larger sample sizes, and subgroup analyzes to see if the results found are restricted to this group or can be inferred for the general population.
Journal of Voice, Vol. &&, No. &&, 2019
19.
20.
CONCLUSIONS Elementary and secondary school teachers have voice symptoms, CMD symptoms, and low voice-related perceived control. The greater the number of CMD symptoms, the greater the occurrence of voice symptoms and the lower the voice-related perceived control.
21.
22.
23.
REFERENCES
1. Dist urbio de Voz Relacionado ao Trabalho − DVRT/Ministerio da Sa ude. Secretaria de Vigil^ancia em Saude, Departamento de Vigil^ancia em Sa ude Ambiental e Saude do Trabalhador. Brasília: Ministerio da Sa ude; 2018. 2. Costa DB, Lopes LW, Silva EG, et al. Fatores de risco e emocionais na voz de professores com e sem queixas vocais. Rev CEFAC. 2013;15: 1001–1009. 3. Simberg S, Laine A, Sala E, et al. Prevalence of voice disorders among future teachers. J Voice. 2000;14:231–235. 4. Ortiz E, de Costa EA, Spina AL, et al. Proposta de modelo de atendimento multidisciplinar para disfonias relacionadas ao trabalho: estudo preliminar. Rev Bras Otorrinolaringol. 2004;49:546–551. 5. Behlau M. The 2016 G. Paul Moore lecture: lessons in voice rehabilitation: Journal of Voice and Clinical Practice. J Voice. 2018. pii: S08921997(18)30052-3. 6. Mestre LR, Ferreira LP. O impacto da disfonia em professores: queixas vocais, procura por tratamento, comportamento, conhecimento sobre cuidados com a voz, e absenteísmo. Rev da Soc Bras Fonoaudiol. 2011;16:240–241. 7. Simberg S. Prevalence of Vocal Symptoms and Voice Disorders Among Teacher Students and Teachers and a Model of Early Intervention. Finland; 2004. 8. Vital HRMC, Lima-Silva MFB, Almeida LNA, et al. Sintomas vocais auditivos e proprioceptivos pre e p os-terapia de grupo de pacientes com disfonia. Rev CEFAC. 2016;18:1189–1199. 9. Almeida AA, Behlau M. Relations between self-regulation behavior and vocal symptoms. J Voice. 2017;31:455–461. 10. Karoly P, Boekaerts M, Maes S. Toward consensus in the psychology of self-regulation: how far have we come? How far do we have yet to travel? Appl Psychol. 2005;54:300–311. 11. Freund AM, Baltes PB. Life-management strategies of selection, optimization, and compensation: measurement by self-report and construct validity. J Pers Soc Psychol. 2002;82:642–661. 12. del Castillo JAG, Dias PC, Castelar-Perim P. Autorregula¸c ~ao e consumo de subst^ ancias na adolesc^encia. Psicol Reflex~ao e Crítica. 2012;25: 238–247. 13. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1–26. 14. Misono S, Meredith L, Peterson CB, et al. New perspective on psychosocial distress in patients with dysphonia: the moderating role of perceived control. J Voice. 2016;30:172–176. 15. Vinney LA, van Mersbergen M, Connor NP, et al. Vocal control: is it susceptible to the negative effects of self-regulatory depletion? J Voice. 2016;30:638.e21–638.e31. 16. Vinney LA, Turkstra LS. The role of self-regulation in voice therapy. J Voice. 2013;27:390.e1–390.e11. 17. Almeida AA, Behlau M. Adapta¸c ~ao cultural do Questionario Reduzido de Autorregula¸c ~ ao: sugest~ oes de aplica¸c ~ao para area de voz. CoDAS. 2017;29:1–5. 18. Maragno L, Goldbaum M, Gianini RJ, et al. Preval^encia de transtor~es atendidas pelo Programa Sa nos mentais comuns em popula¸c o ude
24.
25.
26.
27. 28.
29.
30. 31.
32.
33.
34.
35.
36.
37.
38. 39.
40.
da Família (QUALIS) no Município de S~ao Paulo, Brasil. Cad Saude Publica. 2006;22:1639–1648. Rocha LM, Mattos Souza LD. Voice handicap index associated with common mental disorders in elementary school teachers. J Voice. 2013;27:595–602. ~es de traAparecida E, Servilha M, Manchado P, et al. Condi¸c o balho, sa ude e voz em professores universitarios. Rev Ci^enc Med. 2008;17:21–31. Almeida LNA, Lopes LW, da Costa DB, et al. Características vocais e emocionais de professores e n~ao professores com baixa e alta ansiedade. Audiol Commun Res. 2014;19:179–185. Da Rocha LM, Behlau M, Souza LDDM. Behavioral dysphonia and depression in elementary school teachers. J Voice. 2015;29: 712–717. Deary IJ, Wilson JA, Carding PN, et al. VoiSS: a patient-derived voice symptom scale. J Psychosom Res. 2003;54:483–489. Moreti F, Zambon F, Oliveira G, et al. Cross-cultural adaptation, validation, and cutoff values of the Brazilian version of the voice symptom scale—VoiSS. J Voice. 2014;28:458–468. Frazier P, Keenan N, Anders S, et al. Perceived past, present, and future control and adjustment to stressful life events. J Pers Soc Psychol. 2011;100:749–765. Harding TW, Climent CE, De Arango MV, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med. 1980;10:231–241. Mari JDJ, Williams P. A validity study of a psychiatric screening questionnaire. Br J Psychiatry. 1986;148:23–27. Behlau M, Madazio G, Moreti F, et al. Efficiency and cutoff values of self-assessment instruments on the impact of a voice problem. J Voice. 2016;30:506.e9–506.e18. Gon¸c alves DM, Stein AT, Kapczinski F. Avalia¸c ~ao de desempenho do Self-Reporting Questionnaire como instrumento de rastreamento psiquiatrico: um estudo comparativo com o Structured Clinical Interview for DSM-IV-TR. Cad Saude Publica. 2008;24:380–390. Devore JL. Probabilidade e estatística: para engenharia e ci^encias. S~ao Paulo: Cengage Learning; 2006. Dragone MLS, Ferreira LP, Pinto SP, et al. Voz do professor: uma revis~ao de 15 anos de contribui¸c ~ao fonoaudiol ogica. Rev da Soc Bras Fonoaudiol. 2010;15:289–296. da Silva GJ, Almeida AA, de Lucena BTL, et al. Sintomas vocais e causas autorreferidas em professores. Rev CEFAC. 2016;18: 158–166. Roy N, Merrill RM, Thibeault S, et al. Voice disorders in teachers and the general population effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47: 542–551. Fortes FSG, Imamura R, Tsuji DH, et al. Perfil dos profissionais da voz com queixas vocais atendidos em um centro terciario de sa ude. Rev Bras Otorrinolaringol. 2007;73:27–31. Behlau M, Zambon F, Guerrieri AC, et al. Epidemiology of voice disorders in teachers and nonteachers in Brazil: Prevalence and adverse effects. J Voice. 2012;26:665.e9–665.e18. Lima-Silva MFB, Piccolotto Ferreira L, Bittante de Oliveira I, et al. Voice disorders in teachers: self-report, auditory-perceptive assessment of voice and vocal fold assessment. Rev da Soc Bras Fonoaudiol. 2012;17:391–397. Servilha EAM, da Costa ATF. Conhecimento vocal e a import^ancia da voz como recurso pedag ogico na perspectiva de professores universitarios. Rev CEFAC. 2015;17:13–26. do Amaral AC, Zambon F, Moreti F, et al. Desconforto do trato vocal em professores ap os atividade letiva. CoDAS. 2017;29:1–7. Lima JP, Ribeiro VV, Cielo CA. Sintomas vocais, grau de quantidade de fala e de volume de voz de professores. Disturbios Comum. 2015;27: 129–137. Thomas G, Kooijman PGC, Cremers CWRJ, et al. A comparative study of voice complaints and risk factors for voice complaints in female student teachers and practicing teachers early in their career. Eur Arch Otorhinolaryngol. 2006;263:370–380.
ARTICLE IN PRESS Iandra Kaline Barbosa, et al
Voice Symptoms, Perceived Voice Control, and CMDs
41. Fillis MMA, de Andrade SM, Gonzalez AD, et al. Frequ^encia de problemas vocais autorreferidos e fatores ocupacionais associados em professores da educa¸c ~ao basica de Londrina, Parana, Brasil. Cad Saude Publica. 2016;32: e00026015. 42. Choi-Cardim K, Behlau M, Zambon F. Vocal symptoms and profile of teachers in a vocal health program. Rev CEFAC. 2010;12: 811–819.
7
43. Rocha LM, de Lima Bach S, Amaral PL, et al. Risk factors for the incidence of perceived voice disorders in elementary and middle school teachers. J Voice. 2017;31:258.e7–258.e12. 44. Misono S, Peterson CB, Meredith L, et al. Psychosocial distress in patients presenting with voice concerns. J Voice. 2014;28:753–761. 45. Giacomolli G. A voz como instrumento de trabalho. Rev Educ IDEAU. 2014;9:1–12.
Voice Symptoms, Perceived Voice Control, and Common Mental Disorders in Elementary School Teachers *,†Iandra Kaline Barbosa, ‡Mara Behlau, §Maria Fabiana Lima-Silva, ║Larissa Nadjara Almeida, ║Hemmylly Farias, and §Anna Alice Almeida, *x║Jo~ao Pessoa, yNatal, and zS~ao Paulo, Brazil Summary: Introduction. Evaluating the relationship among teachers’ voice symptoms, perceived voice control, and common mental disorders (CMDs) might contribute to the understanding of the relationship between vocal wear and the teacher well-being. The understanding of this relationship may also help in taking more informed clinical decisions in voice rehabilitation when considering possible perceived voice control difficulties and the need to develop voice self-control strategies. Objective. The aim of this study was to determine the voice symptoms, perceived voice control, and CMDs in public elementary and secondary school teachers, and to analyze the relationships among these variables. Methods. The study included 85 public elementary and secondary school teachers of both genders. Four instruments were used to measure the variables: an identification and characterization questionnaire, the Voice Symptom Scale, the Present Perceived Control of Voice scale, and the Self-Reporting Questionnaire. Results. A significant correlation between voice symptoms and CMDs was found, along with correlations between the emotional domain of the Voice Symptom Scale and teachers’ ages and years of teaching. A negative correlation between CMDs and voice self-control was also observed. Conclusions. Teachers with voice symptoms had more CMD symptoms, and as the number of mental disorder symptoms increased, voice self-control decreased. Key Words: Behavior−Dysphonia−Teachers−Signs and symptoms−Mental disorders−Voice.
INTRODUCTION Among all the topics addressed in the research on teachers, the speech therapy has traditionally worried about voicerelated questions, due to the amount of departures from the learner activity related to voice problems, in addition to that the vocal problems can be considered as a work-related illness.1 Teachers among the professional classes are most affected by voice problems, with significant negative consequences, such as difficulties in teaching, communicating and social and emotional problems.2,3 Dysphonias are showed as vocal problems manifestations and could be from organic and/or behavioral origin.4,5 Teachers are often affected by vocal problems of behavioral origin, results from inadequate use of voice, although they may present any type of dysphonia.6,7 A feature of dysphonia is the presence of voice symptoms of an auditory or proprioceptive nature,8 including vocal fatigue, coughing, hoarseness, burning throat, voice failure, and shortness of breath when speaking.2 In voice professionals, such as teachers, voice patterns can play a greater or lesser role in the origin and maintenance of dysphonia; thus, vocal abuse or misuse Accepted for publication July 23, 2019. From the *Speech Therapy Graduate Program, Universidade Federal da Paraíba − UFPB, Jo~ ao Pessoa, Paraiba, Brazil; yUniversidade Federal do Rio Grande do Norte − UFRN, Natal, Rio Grande do Norte, Brazil; zHuman Communication Disorders Graduate Program, Universidade Federal de S~ao Paulo − UNIFESP, S~ao Paulo, S~ao Paulo, Brazil; xDepartment of Speech Pathology, UFPB, Jo~ao Pessoa, Paraiba, Brazil; and the ║Decision Models and Health Department, UFPB, Jo~ao Pessoa, Paraiba, Brazil. Address correspondence and reprint requests to Anna Alice Almeida, Departamento de Fonoaudiologia, Cidade Universitaria − Campus I, Centro de Ci^encias da Sa ude, Universidade Federal da Paraíba, Castelo Branco, CEP, Jo~ao Pessoa 58051-900, Paraiba, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 Published by Elsevier Inc. on behalf of The Voice Foundation. https://doi.org/10.1016/j.jvoice.2019.07.018
of the voice is directly related to the emergence of dysphonia, and this use could be related to the quantity and intensity of speech and lack of perceived control over one’s own vocal problem.9 The way in which the voice is used, whether in terms of the amount of speech or its vocal intensity, is a very individual characteristic and can be controlled through self-regulation. Self-regulation is a complex process in which the individual plays an active role in controlling oneself to achieve certain goals.10,11 Self-regulation is considered crucial to understanding behavior related to additive and abusive practices, such as smoking, drug use, alcohol, and obesity.12 This process can also be related to vocal behavior because voice use represents a social behavior and requires neuromuscular control, primarily developed for survival purposes.9 This fact has great importance to professional voice users. One study showed that people who have voice symptoms have lower self-regulation levels than those with no voice symptoms; in addition, as voice symptoms increase, there are decreases in impulse control and goal setting.9 Another study reported an experiment observing self-regulatory depletion related to vocal behavior and found that people who perform activities with a low demand for self-regulation can better control their vocal behavior. It is understandable that dysphonic individuals lose auditory motor control in noisy places, in addition to having difficulties with self-regulation, which together contribute to inadequate vocal behavior. Identifying the positive and negative elements of self-regulation in patients with voice disorders during assessments can be important in terms of treatment planning, goal setting, impulse control, practical measures in the patient’s daily life, and the generalization and maintenance of gains in vocal rehabilitation.16,17 In this regard,
ARTICLE IN PRESS 2 voice therapy requires the patient’s dedication and attention to practice new consciously learned behaviors; that is, the clinician must include the self-regulation process in voice therapy.16 Related but distinct from self-regulation is voice-related present perceived control, which is the extent to which the individual believes that he/she can currently control voicerelated events and symptoms, and how he/she reacts to these.13,14 It should be clarified that perceived control is not actual control but rather the assessment that the individual makes of his/her ability to regulate certain behaviors or emotional reactions. This control can be affected by the working conditions to which the teacher is subjected, such as long working days, excessive voice demands, large numbers of listeners, background noise, poor acoustics, distance between speakers, low humidity, dust and mold, stressful environments, and inadequate equipment.2 In addition to these issues, important new data have revealed a disturbing new element of teacher’s vocal health, which is the possibility of suffering from common mental disorders (CMDs). CMDs present as symptoms of anxiety, fatigue, insomnia, forgetfulness, irritability, difficulty concentrating, and somatic complaints.18,19 Patients with CMDs do not generally have a firm psychiatric diagnosis of an anxiety or mood disorder but rather present with symptoms inherent in these disorders. Stress resulting from inadequate working conditions can increase teachers’ voice symptoms and have negative effects on the quality of their performance.2,20,21 In this sense, in addition to voice symptoms being related to voice use, mental health issues may also be associated with voice use, rendering both the correct diagnosis and the treatment of teachers with voice problems difficult.22 High anxiety scores have been identified in teachers with greater numbers of voice symptoms.21 Another study confirmed that teachers with voice complaints have greater numbers of CMD symptoms, indicating the existence of emotional effects in the development and persistence of voice problems.2 Establishing the relationship between vocal symptoms, perceived vocal control, and CMDs in teachers would allow us to better understood vocal exhaustion and illness in this professional class. Furthermore, it is possible to make a more clinical decision based on vocal rehabilitation, considering the possible difficulties of vocal control perceived at the time of rehabilitation and the need to develop vocal self-control strategies. The aims of this study were therefore to measure voice symptoms, self-regulation, voice-related perceived control, and CMDs in public elementary and secondary school teachers, and to analyze the relationships of these variables with each other. It is believed that elementary school teachers present a high number of vocal symptoms, reduced perceived vocal control, and the presence of mental disorders symptoms. In addition, it is expected to find a relationship between these factors studied.
Journal of Voice, Vol. &&, No. &&, 2019
METHODS This study was approved by the Research Ethics Committee from Universidade Federal da Paraíba under protocol number 0824/2015. It was an observational cross-sectional field study, conducted with 85 public elementary and secondary (middle and high) school teachers working in Northeast Brazil. The eligibility criteria for participation in the study were as follows: being an active teacher; working in the Public Education Network; teaching in elementary and/or secondary schools; not having undergone previous voice therapy and/or not undergoing it at the time of the study; and participating in all stages of the study. It is important to know that the population of this study has a particularity related to their voice, besides not behaving like individuals who use the voice as instrument in their work. In this sense, teachers stand out from other individuals because of their vocal characteristics, high vocal demand and their perception of their voice often distorted. Table 1 reports the sample teachers’ work-related characteristics. The volunteer subjects were of both genders, mostly female (70.6%, n = 60). Most taught more than one subject (42.4%, n = 36), were elementary school teachers, that is, taught up to the fifth grade (41.2%, n = 35), and had two daily shifts (54.8%, n = 46). Eleven schools were randomly selected from a list of the public schools provided by the Department of Education of the participating municipality. Subsequently, a representative from each school was contacted to authorize the research at the institution. Then, all of the teachers at the authorized schools were invited to participate by the researcher during a visit. At this time, information about TABLE 1. Characterization of the Sample of Participating Teachers Variables Gender Female Male Subjects taught More than one Humanities Exact sciences Biology Physical education Languages Teaching level Elementary school Middle school High school Higher education More than one Workload One shift Two shifts Three shifts
N
%
60 25
70.6 29.4
36 16 13 8 7 5
42.4 18.8 15.3 9.4 8.2 5.9
35 14 17 1 18
41.2 16.5 20.0 1.2 21.2
31 46 7
36.9 54.8 8.3
ARTICLE IN PRESS Iandra Kaline Barbosa, et al
3
Voice Symptoms, Perceived Voice Control, and CMDs
the purpose of the study was given, and the teachers provided individual informed consent. Data collection included the Identification and Characterization Questionnaire; the Voice Symptom Scale (VoiSS),23 validated in Brazilian Portuguese24; the voice-related Present Perceived Control scale (PPC-V),14,25 culturally and linguistically adapted to Brazilian Portuguese; and the SelfReporting Questionnaire (SRQ-20),26 validated in Brazilian Portuguese.27 The Identification and Characterization Questionnaire is a standardized tool containing questions on personal data, general health, and specific features of the teacher’s profession. This included personal characteristics (such as age, gender, and region where they lived); occupation (education level, number of years teaching, teaching hours per week, and subject taught); and vocal characteristics and history (self-assessed voice quality, voice complaints, prior voice therapy for vocal disorders, absence from work in the previous year because of voice problems, and the need to change teaching style due to voice problems). The VoiSS, developed in England,23 is a self-assessment tool that determines the frequency of voice symptoms of an individual. In this study, the version of the VoiSS translated and validated for Brazilian Portuguese was used.24 The scale has 30 items assessing voice symptoms across three domains—impairment, emotional, and physical— with 10 items each, with answers scaled according to frequency of occurrence: 0 = never; 1 = rarely; 2 = sometimes; 3 = most of the time; and 4 = always. It thus has three partial scores and one total score, calculated simply as the sum of the partial scores. The total score ranges from 0 to 120, with higher values representing greater perception of symptoms and their consequences in daily life due to voice problems. It has a 16-point cutoff value and is considered a psychometrically robust classifier in terms of its diagnostic value for individuals with voice problems.28 The Perceived Control Scale − Stressful Events Scale was developed by Frazier et al25 and was adapted for the study of voice issues as the PPC-V scale.14 This protocol was adapted linguistically and culturally for Brazilian Portuguese before being administered to the teachers. The scale comprises eight questions, four positively phrased and four negatively phrased, which assess the individual’s perception of his/her current ability to control his/her vocal stressor or response to the vocal stressor. The answer scale ranges from 1 to 4, according to agreement with the following statements: 1 = totally disagree; 2 = somewhat disagree; 3 = somewhat agree; and 4 = strongly agree. Negatively formulated questions receive inverse scores. The mean value for a population of 820 respondents was 2.92 points.14 The SRQ-20, previously validated in Brazilian Portuguese,27 has 20 sentences for the assessment of physical and psychological symptoms, with dichotomous responses (yes or no) for aspects relating to somatization, depression, and anxiety. Results greater than 7/8 points for women and 6.5 points for men were used as cutoff points,29 indicating a positive SRQ score (possible presence of CMDs). In this study, a
cut-off value point resulting from a more recent analysis of this questionnaire was used. Descriptive statistical analysis was performed using Microsoft Excel 365 ProPlus to report the means, standard deviations, and frequencies of the analyzed variables, and inferential analysis was conducted based on Pearson’s correlation test. Devore’s30 proposed method was used to assess the strength of the correlations, indicating the degree of correlation according to Pearson’s coefficients, in which a correlation of 0.00−0.19 is regarded as very weak, from 0.20 to 0.39 as weak, from 0.40 to 0.69 as moderate, from 0.70 to 0.89 as strong, and from 0.90 to 1.00 as very strong. RESULTS The study included 85 public school teachers of both genders, with a mean age of 40.1 years old (§9.5). Table 2 presents the teachers’ work-related voice characteristics. Most of the teachers (50.6%; n = 40) assessed their current voice quality as good, had never had a medical consultation for a voice problem (61.2%; n = 52), and had never had a voice therapy session due to voice problems (57.3%, n = 64). Many teachers had missed work because of their voice (55.3%; n = 47), and the majority of teachers reported missing 1−3 days within the past year because of their voice (50.6%; n = 43), and reported that they had needed to change their teaching methods slightly because of their voice (41.2%, n = 35). TABLE 2. Characterization of the Voice Issues of Participating Teachers Variables Opinion about voice quality Excellent Very good Good Fair Poor Had a medical visit Yes No Had a voice therapy session Yes No Absence from work due to voice Yes No No. of days missed due to voice 0 days 1−3 days More than 3 days Changed teaching methods due to voice No A little Moderate A lot
N
%
4 8 43 27 3
4.7 9.4 50.6 31.8 3.5
33 52
38.8 61.2
20 64
23.5 75.3
47 38
55.3 44.7
38 43 4
44.7 50.6 4.7
28 35 17 7
32.9 41.2 17.6 8.2
ARTICLE IN PRESS 4
Journal of Voice, Vol. &&, No. &&, 2019
Table 3 shows the means and standard deviations of the vocal, behavioral, and work-related variables. The participating teachers reported having a mean of 28.3 (§6.53) students per class and 14 (§9.00) years of teaching experience. Regarding the total scores of the protocols used, there was a mean of 15.5 (§7.88) for the VoiSS impairment domain, 5.4 (§4.53) for the emotional domain, 9.1 (§4.91) for the physical domain, 30.2 (§14.55) points for the total score of the VoiSS, 4.3 (§4.25) points for the mean PPC-V, and 7.2 (§4.22) points for the SRQ-20. Table 4 shows a negative correlation between voicerelated perceived control and the presence of CMDs (P = 0.046) as well as positive correlations between CMDs and voice symptoms in the impairment (P = 0.002), emotional (P < 0.0001), physical (P < 0.0001), and total (P < 0.0001) domains. DISCUSSION Teachers constitute the category of voice professionals that has received the highest number of scientific studies in voice research.2,31 Since teachers experience intense voice demands, accumulation of activities, inadequate working environments, poor acoustics, lack of vocal training, and daily contact with elements harmful to the voice, they are more likely to develop dysphonia and to present with voice symptoms.2,19,21,24,32 If a teacher has a voice problem, it might mean that he/she must go on leave, thus harming his/her professional performance, compromising the longevity of his/her career, and generating frustration and feelings of worthlessness.21,32−35 In addition, in such conditions, the professional can require readaptation, which can result in personal, economic, and professional problems, as well as functional problems for the school.36 Most of the present study’s teachers considered their voice quality good, had never had medical visits or voice therapy sessions for voice problems, did not smoke, did not
TABLE 3. Means and Standard Deviations of Personal, Organizational, Vocal, and Behavioral Variables Variable
Mean
Standard Deviation
Age Mean number of students per class Years of teaching VoiSS impairment VoiSS emotional VoiSS physical VoiSS total PPC-V total SRQ-20 total
40.12 28.31 14.98 15.54 5.4 9.1 30.29 4.3 7.2
9.56 6.53 9.00 7.88 4.53 4.91 14.55 4.25 22.00
Abbreviations: VoiSS, Voice Symptom Scale; PPC-V, Present Perceived Control of Voice Scale; SRQ-20, Self-Reporting Questionnaire.
TABLE 4. Correlation Between Vocal and Behavioral Variables Variables VoiSS Impairment PPC-V − Total SRQ-20 − Total VoiSS Emotional PPC-V − Total SRQ-20 − Total VoiSS Physical PPC-V − Total SRQ-20 − Total VOISS − Total PPC-V − Total SRQ-20 − Total PPC-V − Total SQR-20 − Total
Test Statistic
P Value
0.009 0.337
0.936 0.002*
0.011 0.451
0.919 0.0001*
0.001 0.417
0.996 0.0001*
0.023 0.470
0.837 0.0001*
0.300
0.046*
* P < 0.05. Abbreviations: VoiSS, Voice Symptom Scale; PPC-V, Present Perceived Control of Voice Scale; SRQ-20, Self-Reporting Questionnaire. Test: Pearson’s correlation.
drink, did not have constant colds or other recurring issues, were physically active, reported hearing well, and had no family members with voice problems. Although teachers often consider their voice quality to be good, it does not indicate a lack of voice complaints or even of disorders. Often, these professionals tend to minimize voice disorder symptoms because they consider it simply to be an expected consequence of their teaching activity.37 Although the teachers perceived their voice quality to be good, many had to miss work due to voice problems and even change their methods of teaching. Research has shown that teachers with voice complaints mention experiencing more voice symptoms and self-assess their voice quality as worse than teachers without voice complaints,2 and teachers at vocal risk assess their voice quality as poor, whereas teachers without vocal risk self-assess positively, showing that the individual’s perception of his/her voice quality can be associated with the onset of voice symptoms.38 Most of the teachers in this study had high voice demands because they had to teach more than one subject, and they worked two daily shifts. Commonly, elementary school teachers (first to fifth grade) are responsible for teaching all subjects, which increases the voice demand and the need for vocal adaptations.39 Dysphonia in teachers can be due to associated external factors, such as high voice demand, large numbers of students in classes, inadequate working environments, large workloads, accumulation of activities, poor acoustics, and daily contact with work-related elements harmful to the voice.2,21,40 There is a prevalence of voice problems in teachers with workloads equal to or greater than 40 hours/week; that is, the higher that the workload is, the greater the use of the voice is, as well as the possibility of developing voice problems.41
ARTICLE IN PRESS Iandra Kaline Barbosa, et al
Voice Symptoms, Perceived Voice Control, and CMDs
A teacher’s high daily workload means that it is possible that working more than one shift will result in greater vocal demands and will consequently foster the emergence of voice symptoms.42 If a teacher develops dysphonia, it can lead to absence from work and can therefore be considered a work-related disease.1 This professional class routinely shows the need to take sick leave due to voice problems and even to leave their jobs permanently.43 Any change in these professionals’ voices can indicate the inability to perform their job duties and result in absenteeism, decreased productivity, and even the need to change professions.34 Many teachers report voice problems at some point in their lives, whether occasionally or frequently. The mean number of voice symptoms in the Brazilian population is 1.7, and in teachers, it is 3.5. Thus, at least one in every two teachers active have voice complaints and/or voice symptoms.35 The teachers participating in this study had a mean score that was higher than the VoiSS cutoff value, although the VoiSS cutoff was calculated for a general dysphonic population and not specifically for teachers. Considering that this value might be different for this professional category, the teachers in this sample showed similar characteristics to people with voice problems.24 The symptoms most commonly found in this professional category are hoarseness, vocal fatigue, a weak voice, voice failure, pain or discomfort when speaking, a dry throat, throat clearing, persistent coughing, and difficulty in projecting the voice. These symptoms could result from misuse or excessive use of the voice in poor working conditions that favor the emergence of occupational diseases.32 Another worrying aspect that affects teachers’ vocal health is the possibility that these individuals suffer from CMDs.21 In this study, the mean SRQ score was greater than the cutoff value, showing that the teachers in this study had a propensity toward CMDs, which involve symptoms of irritability, fatigue, insomnia, difficulty concentrating, forgetfulness, anxiety, and somatic complaints, often going undiagnosed and do not causing patients to seek medical care despite there being an apparent increase in these symptoms in several countries.18 Symptoms related to anxiety, stress, and depression can affect an individual’s voice characteristics and quality of life directly, especially in people who use their voices as a tool in their work, such as teachers.2,19,21,22 A strong, positive correlation was observed between voice symptoms and CMDs. The VoiSS scores in all domains were correlated positively with the total SRQ-20 score, indicating that the greater the number of voice symptoms is, the more frequent the presence of CMD symptoms. Individuals with voice problems commonly have a high prevalence of various types of distress symptoms, such as depression, anxiety, and/or somatic changes. This finding suggests the need for more studies on the relationship between these symptoms and voice problems.44 It has been shown that teachers with voice problems have higher incidences of depression and generalized anxiety disorder. In addition, there is a strong association between
5
behavioral dysphonia and psychosocial symptoms.45 Data such as these indicate the need for a greater focus by speech therapists on teachers’ voice disorders given the importance of the voice to their mental health since teachers who manifest voice complaints report more voice symptoms and have a higher prevalence of CMD symptoms.2 Another important finding in this study was the strong negative correlation between voice-related perceived control and SRQ-20 scores, suggesting that, the more psychosocial symptoms are related the lower the voice-related perceived control. This study design does not allow us to assess whether the psychosocial symptoms lead to decreased voice-related perceived control or vice versa. In the context of voice therapy, voice-related perceived control is the ability that the individual currently has to control his/her vocal symptoms, such as through behaviors or adaptations, and his/her perceptions of how the voice responds and adjusts to these episodes.14,42 The PPC-V was used to assess the voice-related perceived control of the teachers in this study. Although some research has found a strong relationship between voice symptoms (as measured by VHI-10) and voice-related perceived, no significant correlation between these two parameters was found in this study. In contrast, it was observed that this study’s teachers scored a mean of 4.3 points on the PPC-V, which was greater than the score found in the instrument’s validation study, which was 2.92 points.14 Self-regulation is the ability to voluntarily control one’s own thinking and behavior.16 It is a very complex phenomenon and involves many other aspects, such as activation, monitoring, inhibition, preservation, adaptation, and managing emotions and cognitive strategies to achieve the desired goals.9,13 The voice characteristics and working conditions of teachers, coupled with reduced voice-related perceived control and self-regulation, could lead to worsening the vocal condition and delay the search for treatment.43 Individuals with voice symptoms have shown lower levels of self-regulation than those without voice symptoms, and as the number of voice symptoms increases, impulse control and goal-setting scores decrease.9 Other studies have found that individuals with voice complaints and/or symptoms who are undergoing voice therapy are asked to make changes to their vocal behavior and must use selfregulation for this change to occur,15 either through goal setting or through impulse control. It is assumed that individuals with dysphonia have learned inappropriate vocal behaviors throughout their lives, so voice therapy demands attention and effort to change behavior not under conscious command.16 Although the relationship among anatomical, physiological, and psychological aspects has been much studied, the contribution of cognitive factors to the success or failure of this process has received little attention.16 The group studied is exclusive to teachers, therefore it is not possible to generalize the data, besides that the time of vocal symptom and the degree of vocal deviation are variables that could not be controlled in this research.
ARTICLE IN PRESS 6 Future studies will include comparison methods, larger sample sizes, and subgroup analyzes to see if the results found are restricted to this group or can be inferred for the general population.
Journal of Voice, Vol. &&, No. &&, 2019
19.
20.
CONCLUSIONS Elementary and secondary school teachers have voice symptoms, CMD symptoms, and low voice-related perceived control. The greater the number of CMD symptoms, the greater the occurrence of voice symptoms and the lower the voice-related perceived control.
21.
22.
23.
REFERENCES
1. Dist urbio de Voz Relacionado ao Trabalho − DVRT/Ministerio da Sa ude. Secretaria de Vigil^ancia em Saude, Departamento de Vigil^ancia em Sa ude Ambiental e Saude do Trabalhador. Brasília: Ministerio da Sa ude; 2018. 2. Costa DB, Lopes LW, Silva EG, et al. Fatores de risco e emocionais na voz de professores com e sem queixas vocais. Rev CEFAC. 2013;15: 1001–1009. 3. Simberg S, Laine A, Sala E, et al. Prevalence of voice disorders among future teachers. J Voice. 2000;14:231–235. 4. Ortiz E, de Costa EA, Spina AL, et al. Proposta de modelo de atendimento multidisciplinar para disfonias relacionadas ao trabalho: estudo preliminar. Rev Bras Otorrinolaringol. 2004;49:546–551. 5. Behlau M. The 2016 G. Paul Moore lecture: lessons in voice rehabilitation: Journal of Voice and Clinical Practice. J Voice. 2018. pii: S08921997(18)30052-3. 6. Mestre LR, Ferreira LP. O impacto da disfonia em professores: queixas vocais, procura por tratamento, comportamento, conhecimento sobre cuidados com a voz, e absenteísmo. Rev da Soc Bras Fonoaudiol. 2011;16:240–241. 7. Simberg S. Prevalence of Vocal Symptoms and Voice Disorders Among Teacher Students and Teachers and a Model of Early Intervention. Finland; 2004. 8. Vital HRMC, Lima-Silva MFB, Almeida LNA, et al. Sintomas vocais auditivos e proprioceptivos pre e p os-terapia de grupo de pacientes com disfonia. Rev CEFAC. 2016;18:1189–1199. 9. Almeida AA, Behlau M. Relations between self-regulation behavior and vocal symptoms. J Voice. 2017;31:455–461. 10. Karoly P, Boekaerts M, Maes S. Toward consensus in the psychology of self-regulation: how far have we come? How far do we have yet to travel? Appl Psychol. 2005;54:300–311. 11. Freund AM, Baltes PB. Life-management strategies of selection, optimization, and compensation: measurement by self-report and construct validity. J Pers Soc Psychol. 2002;82:642–661. 12. del Castillo JAG, Dias PC, Castelar-Perim P. Autorregula¸c ~ao e consumo de subst^ ancias na adolesc^encia. Psicol Reflex~ao e Crítica. 2012;25: 238–247. 13. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1–26. 14. Misono S, Meredith L, Peterson CB, et al. New perspective on psychosocial distress in patients with dysphonia: the moderating role of perceived control. J Voice. 2016;30:172–176. 15. Vinney LA, van Mersbergen M, Connor NP, et al. Vocal control: is it susceptible to the negative effects of self-regulatory depletion? J Voice. 2016;30:638.e21–638.e31. 16. Vinney LA, Turkstra LS. The role of self-regulation in voice therapy. J Voice. 2013;27:390.e1–390.e11. 17. Almeida AA, Behlau M. Adapta¸c ~ao cultural do Questionario Reduzido de Autorregula¸c ~ ao: sugest~ oes de aplica¸c ~ao para area de voz. CoDAS. 2017;29:1–5. 18. Maragno L, Goldbaum M, Gianini RJ, et al. Preval^encia de transtor~es atendidas pelo Programa Sa nos mentais comuns em popula¸c o ude
24.
25.
26.
27. 28.
29.
30. 31.
32.
33.
34.
35.
36.
37.
38. 39.
40.
da Família (QUALIS) no Município de S~ao Paulo, Brasil. Cad Saude Publica. 2006;22:1639–1648. Rocha LM, Mattos Souza LD. Voice handicap index associated with common mental disorders in elementary school teachers. J Voice. 2013;27:595–602. ~es de traAparecida E, Servilha M, Manchado P, et al. Condi¸c o balho, sa ude e voz em professores universitarios. Rev Ci^enc Med. 2008;17:21–31. Almeida LNA, Lopes LW, da Costa DB, et al. Características vocais e emocionais de professores e n~ao professores com baixa e alta ansiedade. Audiol Commun Res. 2014;19:179–185. Da Rocha LM, Behlau M, Souza LDDM. Behavioral dysphonia and depression in elementary school teachers. J Voice. 2015;29: 712–717. Deary IJ, Wilson JA, Carding PN, et al. VoiSS: a patient-derived voice symptom scale. J Psychosom Res. 2003;54:483–489. Moreti F, Zambon F, Oliveira G, et al. Cross-cultural adaptation, validation, and cutoff values of the Brazilian version of the voice symptom scale—VoiSS. J Voice. 2014;28:458–468. Frazier P, Keenan N, Anders S, et al. Perceived past, present, and future control and adjustment to stressful life events. J Pers Soc Psychol. 2011;100:749–765. Harding TW, Climent CE, De Arango MV, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med. 1980;10:231–241. Mari JDJ, Williams P. A validity study of a psychiatric screening questionnaire. Br J Psychiatry. 1986;148:23–27. Behlau M, Madazio G, Moreti F, et al. Efficiency and cutoff values of self-assessment instruments on the impact of a voice problem. J Voice. 2016;30:506.e9–506.e18. Gon¸c alves DM, Stein AT, Kapczinski F. Avalia¸c ~ao de desempenho do Self-Reporting Questionnaire como instrumento de rastreamento psiquiatrico: um estudo comparativo com o Structured Clinical Interview for DSM-IV-TR. Cad Saude Publica. 2008;24:380–390. Devore JL. Probabilidade e estatística: para engenharia e ci^encias. S~ao Paulo: Cengage Learning; 2006. Dragone MLS, Ferreira LP, Pinto SP, et al. Voz do professor: uma revis~ao de 15 anos de contribui¸c ~ao fonoaudiol ogica. Rev da Soc Bras Fonoaudiol. 2010;15:289–296. da Silva GJ, Almeida AA, de Lucena BTL, et al. Sintomas vocais e causas autorreferidas em professores. Rev CEFAC. 2016;18: 158–166. Roy N, Merrill RM, Thibeault S, et al. Voice disorders in teachers and the general population effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47: 542–551. Fortes FSG, Imamura R, Tsuji DH, et al. Perfil dos profissionais da voz com queixas vocais atendidos em um centro terciario de sa ude. Rev Bras Otorrinolaringol. 2007;73:27–31. Behlau M, Zambon F, Guerrieri AC, et al. Epidemiology of voice disorders in teachers and nonteachers in Brazil: Prevalence and adverse effects. J Voice. 2012;26:665.e9–665.e18. Lima-Silva MFB, Piccolotto Ferreira L, Bittante de Oliveira I, et al. Voice disorders in teachers: self-report, auditory-perceptive assessment of voice and vocal fold assessment. Rev da Soc Bras Fonoaudiol. 2012;17:391–397. Servilha EAM, da Costa ATF. Conhecimento vocal e a import^ancia da voz como recurso pedag ogico na perspectiva de professores universitarios. Rev CEFAC. 2015;17:13–26. do Amaral AC, Zambon F, Moreti F, et al. Desconforto do trato vocal em professores ap os atividade letiva. CoDAS. 2017;29:1–7. Lima JP, Ribeiro VV, Cielo CA. Sintomas vocais, grau de quantidade de fala e de volume de voz de professores. Disturbios Comum. 2015;27: 129–137. Thomas G, Kooijman PGC, Cremers CWRJ, et al. A comparative study of voice complaints and risk factors for voice complaints in female student teachers and practicing teachers early in their career. Eur Arch Otorhinolaryngol. 2006;263:370–380.
ARTICLE IN PRESS Iandra Kaline Barbosa, et al
Voice Symptoms, Perceived Voice Control, and CMDs
41. Fillis MMA, de Andrade SM, Gonzalez AD, et al. Frequ^encia de problemas vocais autorreferidos e fatores ocupacionais associados em professores da educa¸c ~ao basica de Londrina, Parana, Brasil. Cad Saude Publica. 2016;32: e00026015. 42. Choi-Cardim K, Behlau M, Zambon F. Vocal symptoms and profile of teachers in a vocal health program. Rev CEFAC. 2010;12: 811–819.
7
43. Rocha LM, de Lima Bach S, Amaral PL, et al. Risk factors for the incidence of perceived voice disorders in elementary and middle school teachers. J Voice. 2017;31:258.e7–258.e12. 44. Misono S, Peterson CB, Meredith L, et al. Psychosocial distress in patients presenting with voice concerns. J Voice. 2014;28:753–761. 45. Giacomolli G. A voz como instrumento de trabalho. Rev Educ IDEAU. 2014;9:1–12.